ACCREDITATION MANUALSection IIPolicies

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EDITED MARCH 2018

ACEN Accreditation Manual POLICIES

A publication of the Accreditation Commission for Education in Nursing REVISED: OCTOBER 2016 Edited: MAY 2017 Revised: JULY 2017 Revised: OCTOBER 2017 Edited: JANUARY 2018 Edited: MARCH 2018 ACEN 3343 Peachtree Road NE, Suite 850 Atlanta, Georgia 30326 Phone: 404.975.5000 Fax: 404.975.5020 Website: www.acenursing.org Copyright 2017 Accreditation Commission for Education in Nursing. All Rights Reserved

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TABLE OF CONTENTS SECTION II - POLICIES POLICY #1 CODE OF CONDUCT AND CONFLICT OF INTEREST .................................... 1

CONFLICT OF INTEREST FOR PEER EVALUATORS .................................................................................. 1CONDUCT AND ETHICAL GUIDELINES FOR NURSING PROGRAMS AND PEER EVALUATORS ......................................................................................................................................................... 2RESPONSIBILITIES OF NURSING PROGRAMS SEEKING ACCREDITATION......................................................... 2RESPONSIBILITIES OF PEER EVALUATORS ...................................................................................................................... 2ACTIONS TO BE AVOIDED BY PEER EVALUATORS .................................................................................................... 3

CONFLICT OF INTEREST, CONDUCT, AND ETHICAL GUIDELINES FOR ACEN STAFF ............. 3CONFIDENTIALITY AND COMMUNICATIONS FOR PEER EVALUATORS AND ACEN STAFF .. 3DISCLOSURE MEMORANDUM AND COMMITMENT TO COMPLY WITH ACEN CODE OF CONDUCT AND CONFLICT OF INTEREST POLICY #1.......................................................................... 5

POLICY #2 REPRESENTATION ON SITE VISIT TEAMS, EVALUATION REVIEW PANELS AND THE BOARD OF COMMISSIONERS .............................................................. 6

NURSE EDUCATORS ............................................................................................................................................ 6NURSING CLINICIANS/PRACTITIONERS ...................................................................................................... 6PUBLIC MEMBERS .................................................................................................................................................. 6

POLICY #3 ELIGIBILITY FOR ACCREDITATION .................................................................... 8POLICY #4 TYPES OF COMMISSION ACTIONS ON APPLICATIONS FOR

ACCREDITATION .................................................................................................................... 12INITIAL ACCREDITATION ............................................................................................................................... 12GRANTED .................................................................................................................................................................................. 12DENIED ....................................................................................................................................................................................... 12

CONTINUING ACCREDITATION ................................................................................................................. 12GRANTED .................................................................................................................................................................................. 12DENIED ....................................................................................................................................................................................... 13

ACCREDITATION WITH CONDITIONS OR WARNING STATUS ..................................................... 13POLICY #5 NOTIFICATION OF COMMISSION DECISIONS .............................................. 16

OTHER GROUPS TO BE INFORMED ............................................................................................................ 16INFORMATION PROVIDED TO THE SECRETARY OF EDUCATION, U.S. DEPARTMENT OF EDUCATION ......................................................................................................................................................... 16

POLICY #6 DELAY/ADVANCEMENT OF CONTINUING ACCREDITATION VISIT ....... 18POLICY #7 VOLUNTARY WITHDRAWAL FROM ACEN ACCREDITATION .................. 19POLICY #8 OPPORTUNITIES FOR THIRD-PARTY COMMENTS ON NURSING

PROGRAMS SCHEDULED FOR INITIAL OR CONTINUING ACCREDITATION ......... 20POLICY #9 DISCLOSURE OF INFORMATION ABOUT THE PROGRAM.......................... 21POLICY #10 APPEAL PROCESS AND SUBMISSION AND REVIEW OF NEW

FINANCIAL INFORMATION SUBSEQUENT TO ADVERSE ACTION ........................... 22DECISIONS ELIGIBLE FOR APPEAL ................................................................................................................ 22GROUNDS FOR APPEAL ................................................................................................................................... 22SUBMISSION AND REVIEW OF NEW FINANCIAL INFORMATION SUBSEQUENT TO ADVERSE ACTION .................................................................................................................................................................. 22NOTICE OF APPEAL ........................................................................................................................................... 23APPOINTMENT OF AN APPEAL COMMITTEE ........................................................................................... 23PROCEDURES FOR GOVERNING THE APPEAL PROCESS AND APPEAL HEARING..................... 24DOCUMENTS FOR THE HEARING ................................................................................................................ 24THE HEARING ...................................................................................................................................................... 25CONDITIONS ....................................................................................................................................................... 27RIGHTS AND LIMITATIONS ............................................................................................................................ 27ACTIONS ................................................................................................................................................................ 28

POLICY #11 PUBLIC NOTICE OF PROPOSED POLICY CHANGES .................................. 30POLICY #12 NURSING PROGRAM RECORDS ON FILE ....................................................... 31

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POLICY #13 INTERIM REPORT (NOT IN EFFECT) ............................................................... 31POLICY #14 REPORTING SUBSTANTIVE CHANGES .......................................................... 32

NURSING PROGRAM OBLIGATIONS........................................................................................................... 32PROCEDURE FOR REPORTING A SUBSTANTIVE CHANGE: ............................................................... 33AN OVERVIEW ..................................................................................................................................................... 33POLICY STATEMENTS REGARDING SUBSTANTIVE CHANGE ............................................................. 33COMMISSION RESPONSIBILITIES ................................................................................................................... 35NURSING PROGRAM RESPONSIBILITIES ..................................................................................................... 36TYPES OF COMMISSION ACTIONS .............................................................................................................. 36REPORTING THE VARIOUS TYPES OF SUBSTANTIVE CHANGE ......................................................... 36GLOSSARY OF TERMS ....................................................................................................................................... 46PROCEDURE 1 PROSPECTUS ...................................................................................................................... 47DIRECTIONS ......................................................................................................................................................... 47REQUIRED INFORMATION BY TYPE OF SUBSTANTIVE CHANGE .................................................... 47PROCEDURE 2 LETTER OF NOTIFICATION .......................................................................................... 49DIRECTIONS ......................................................................................................................................................... 49REQUIRED INFORMATION BY TYPE OF SUBSTANTIVE CHANGE .................................................... 49PROCEDURE 3 - CLOSINGS ............................................................................................................................ 50DIRECTIONS ......................................................................................................................................................... 50

POLICY #15 DISTANCE EDUCATION ..................................................................................... 51GLOSSARY OF TERMS ....................................................................................................................................... 51DISTANCE EDUCATION CRITICAL ELEMENTS: ............................